| LOUISIANA SOBER LIVING

How motivated are you towards recovery?*

0 no motivation - 5 highly motivated

Please give us an idea of how motivated you are toward your recovery.

Personal Information

Full Name

First Middle Last

Date of Birth*

Phone (Where You Can Be Reached)*

Email

Do You Consider Yourself an Alcoholic?*

Yes
No
Maybe

Do You Consider Yourself an Addict?*

Yes
No
Maybe

Sober Date (Date after last drink or use)*

Financials

Are you currently employed*

Yes
No
I am not employed but I have a job lined up

Who is your current employer?

Are you receiving welfare or other non-job related income?

Yes
No
I do not currently but I have applied

Amount you or a loved one able to pay upon ENTERING the house?*

All Fees (rent + deposit + admin fee)
Something (Not All)
Nothing

Amount you are able to pay upon entering*

Please enter a number greater than or equal to 100.

What non-job related income do you recieve?

Previous and Current Legal Issues

Current Legal Situation

I have charges pending
I have no charges pending but have a record
I do not have a criminal record but have charges pending
I do not have a criminal record and no charges are pendng

Are you a sex offender?*

Yes
No
I am, but not obligated to report this.

Treatment Information

Are you currently in a treatment center or detox?*

Yes
No

How many times have you been to chemical dependency treatment?*

Please enter a number from 0 to 20.

Most Recent Treatment Facility

Current Facility Client ID (if applicable)*

Counselor's Name

First Last

Counselor's Phone

Medical Information

Drug of preference/choice?*

Have you ever overdosed?*

Yes
No

How many times have you overdosed?

Please explain your "other" drugs of choice that were not listed.*

Aknowlegements

Please acknowledge that you meet or are willing to meet the following requirements by initialing next to requirement. If it is determined that this acknowledgment is false, the resident will be expelled from Riverhouse immediately

I acknowledge and agree that as a member of the Riverhouse community, I must agree to a minimum commitment of three (3) month stay.*

Agree

I acknowledge and agree that as a member of the Riverhouse community, I must agree to a minimum commitment of three (3) month stay.

All house members understand they are NOT tenants of Riverhouse, but rather guests in our home. I agree that I am not protected by, nor will I invoke any protections of local landlord tenant laws. If it is found that local landlord tenant law applies, I hereby renounce any rights that I may or may not have relating to same.*

Agree

Sober Living Application